PUBLISHED IN Social Analysis:

The International Journal of Social and Cultural Practice, 2011, 55(1): 94-112

The Body Inside Out: Menstrual management and

gynaecological practice in Brazil

Emilia Sanabria
École des hautes études en sciences sociales, Paris

ABSTRACT: Drawing on ethnographic work on menstruation and

gynaecological examinations and surgeries in Salvador (Brazil), this
article explores the way bodily boundaries are constituted through
medical practices. It focuses on the re-enactment of the boundary
between the inside and the outside of bodies with a focus on what is
detached from bodies and which, by falling away from them,
contributes to their constitution. It then considers how the
gynaecological examination and vaginal plastic surgery can be used
to speak of the problematic and contingent act of delimiting the
inside from the outside of bodies.

KEYWORDS: abject, bodily boundaries, Brazil, corporeality,

dys-appearance, interiority

INTRODUCTION
We may call it a border; abjection is above all ambiguity.
– Julia Kristeva, Powers of Horror, An Essay on Abjection

As a substance that flows from the bodily depths out, menstrual blood is
carefully managed, concealed, contained and increasingly suppressed through
the use of hormonal contraceptives. We can read the management of this flow
of blood as a means of working on the body’s boundaries, that is, of
demarcating the body’s inside from its outside. Drawing on ethnographic work
conducted in a range of clinical contexts in Salvador (Brazil) I show that, in this
context, parts of what may initially appear to belong to the body’s interior –
such as the vagina or the uterus – cannot be clearly considered as inside nor

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outside the body. Menstrual bleeding and the gynaecological practices
described here attest to the porous nature of bodily boundaries,
problematising not just the boundary between inside and outside but the very
distinction between them. In the final section I draw on this discussion to
suggest a possible explanation for what the feminist movement calls an
epidemic of vaginal plastic surgery in Brazil.
Bodies play a crucial role in contemporary urban Brazilian sociality. Whilst
much attention has been given to the way bodies are externally delimited
through extensive personal-trainer led work-out sessions, plastic surgery,
dieting or the use of amphetamine-like drugs for weight-loss, less attention has
been given to the surfacing of the body’s interiority. Yet just as striking is the
extensive use made in Brazil of imagining techniques (PET scans, MRIs,
ultrasound, etc), clinical blood tests or any other medical intervention that
gives access to truths about the bodily depths. Some women are even able to
state the volume of their uterine cavity, measured in cm3. Likewise, many of
the women I encountered relayed in tremendous detail the minutia of
menstrual cycle changes (some even citing their oestrogen or FSH levels).
Careful control of bodily and emotional states in Brazil seems to have been
important at least as far back as the hygienist campaigns that marked the turn
of the 20th century. Today, with the growing availability of clinical exams
people have a new set of tools at their disposal to assess, measure and quantify
their bodies’ internal metamorphoses. This marked attention to bodies and
their processes is not limited to the assessments made possible by these
medical technologies. Rather their prevalence attests to the fact that these
respond to existing concerns. Medical techniques that render internal bodily
processes knowable in new ways are particularly appreciated and avidly
consumed. Test results and images are carefully stored and participating in
these diagnostic procedures widely understood as integral to being a
knowledgeable modern individual. This forms the basis of a form of what we
may call diagnostic sociality in which patients take on medical know-how and
use it informally to diagnose one another or discuss the particular regimens
adopted in a range of strategies of biomedical self-enhancement. The uses
made of these medical technologies of self-scoping are central to class
processes in Brazil and reflect shifting aspirations for social inclusion or
upward mobility.
The material presented here was gathered as part of a larger research project
on menstruation and contraceptive use in Bahia (in Salvador and two small
towns of the interior in northeastern Brazil). Over the course of 18 months, I
attended several hundred family planning consultations in public sector health
services, many of which included a gynecological examination. Access to
medical consultations in the private health sector was more limited. I also
carried out interviews with women across the class spectrum. These women
were all urban (although some were of rural origin) and of mixed socio-
economic back- ground. There are substantial differences in the manner in

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which low-income and middle- or upper-class women relate to the body and
medical practices. This article speaks to the way that the pace set by the
private health sector, which is accessed by roughly 25 percent of Brazilians
through health insurance, shapes the aspirations of those who are dependent
on public health.1
Women across the class spectrum are remarkably aware of their body and its
cyclical changes, revealing the manner in which they have appropriated and
given meaning to the symptoms linked to the menstrual cycle. Somewhat
paradoxically, they simultaneously speak of the body as something other than
“them”. The things that their bodies do are narrated as things that happened
to them and that they struggle to reconcile to their-selves. In his book The
Absent Body, phenomenologist Drew Leder (1990) proposes a model to
account for this disjunction between the lived body and the self. Leder
proposes that Cartesian dualism is grounded in experience, a fact which
accounts for the tenaciousness of mind-body distinctions within and beyond
Western culture, suggesting, for him, the existence of a pre-cultural
phenomenological body. His suggestion is that the general mode of
embodiment is one in which, experientially, the body is absent. In the everyday
experience of the body – which he refers to as “ecstatic” corporeality – the
body disappears from experience, as it is turned onto the world. Ecstatic
corporeality is contrasted to bodily dys-appearance, the process where, in
injury or illness, the body is foregrounded in our experience. When the body
dys-appears, the otherwise taken-for-granted body is drawn “out of self
concealment”, emerging as “an alien presence” (Leder 1990:76). Leder
distinguishes between surface and depth dys-appearance, arguing that the inner
or viscous body is even more elusive than the surface, ecstatic body. A viscus,
he argues, cannot be “summoned for personal use, turned ecstatically onto the
world” (1990:55) as a surface organ may be.
I cannot act from my inner organs in the way I do from my surface
musculature. Though I can lift my arm without any problem, I cannot in the
same way choose to secrete a little more bile or accelerate my digestion. The
“magical” sway I have over my own body that Merleau-Ponty describes thus
refers primarily to the body surface. The depths involve an even deeper
sorcery extending beyond my domain. (1990:48)
Leder proposes that it follows that the subject (“I,” in his text) experiences
this disappearing visceral body as other, as an object.
In what follows, I argue that whilst this model may be useful for understanding
the importance, in Brazilian urban centres, of techniques that seek to bring the
“visceral circuitry” to the surface it is based on a number of problematic
assumptions. For example, it assumes that the boundary between inside and
outside is given. One illustration of how we cannot assume anything about
what is inside and what is outside the body is given by Marilyn Strathern, albeit
from a markedly different context. Drawing on Mosko’s (1985) work, she

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describes how the Mekeo of Papua New Guinea understand the body’s
topology:
The inside of a Mekeo person’s body includes or encompasses an outside.
The digestive tract and abdomen is not regarded as the innermost part of a
person but, to the contrary, as a passage connected to the outside world,
which makes it an appropriate repository of food: The tract is part of the
outside that is inside the body. Conversely, wastes from the inside body
accumulate in the abdomen and are regarded as the body’s interior extruded
so its appears on the outside (Strathern 2004:10).
Returning to the Brazilian context, I want to suggest that the management of
menstrual blood through social norms and prescriptions or ideas of hygiene
can be read as an effort to create and police this boundary between inside and
outside. Practices surrounding menstrual blood reveal the careful management
and delimitation of bodily orifices and surfaces. The specific context in which
menstrual blood is revealed is central to its construction as disgusting or as
mess. This opens up the possibility of exploring analytically the production of
appropriate and inappropriate visible contexts for menstrual blood, and thus
to ask questions to the kinds of social relations that are both legitimated by
and produced through its circulation.

MANAGING MENSTRUAL BLOOD

Referring back to her menarche experience in a small rural community, where
sanitary products were rare, Mara, a woman of 28, commented that hiding the
fact that one bled is both necessary and difficult. Bleeding through one’s
clothes is the cause of tremendous embarrassment, and something that
happened several times, such as during a church service, which she recounted
with emotion. Part of the difficulty stems from the fact that it was about
learning vergonha (shame), and about being called to account at such a young
age for failing to manage the effluence of blood.
I remember that my mother became extremely embarrassed when she
realised that the boys had realised that I had…that I was bleeding. A mark had
appeared on my clothes. I did not realise. And she called me to account about
this. As if I should have been more careful. Because I had not perceived, and
my mother gave me a signal, indicating that I should know to care for myself:
‘you have to look’.
This illustrates that it is the public appearance of menstrual blood that causes
embarrassment. It also reveals that this embarrassment has to be taught to the
young girl, as this shame is not obvious. When leakages occur and menstrual
blood appears, staining clothes, these cease to function as an impermeable
boundary that conceals the body. One interviewee, a woman of over 80, drew
connections between menstrual and post-partum resguardos (seclusion

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rituals/proscriptions), emphasising the ways in which these sought to manage
the flow of blood.
If you went back to work before one month had passed [after a birth], it
would bleed a lot because the dona do corpo (mistress of the body term for
uterus) would come out, you had corpo aberto (open body) and the
menstruation would come down. […] Because we didn’t have child in the
maternity [unit], it was all in the hand of the midwife, so you had to lay down
for 4 days and couldn’t get up because it was normal birth and you couldn’t
go out because it was so much blood. [One] soiled so many clothes, my
daughter! So many. And this was a huge shame that women had, no one could
look there. When a visitor arrived, you wouldn’t even hear of a man going
into the woman’s room! And the girls would steal a look at the baby, and the
women would say: “girl, look and see if you can see a stain of (sic.) my
clothes.” (Maria de Jesus)
Menstrual blood, and bodily substances more generally, are subject to careful
management in Brazilian households. The presence of domestic employees or
service workers (porters, drivers, delivery boys, etc.) in the majority of middle
class households makes these spaces as a whole less intimate, so to speak. This
is spatially and structurally reproduced through the division of middle class
living spaces into three distinct zones: “social,” “service” and “private” spaces.2
Even in the smallest of middle class Salvadorian flats there are domestic
quarters with a separate toilet, delimiting a space of intimacy (and substance
circulation) between employers and employees. Most apartment blocks have
two sets of lifts and flats have two distinct entrances (“service” and “social”) as
well as a distinct “social” bathroom, for visitors, whilst the master-bedroom
has a (private) en-suite. The negotiation of employer/employee relations is the
subject of endless disquisition in Brazil soap operas or women’s magazines and
the questions of hygiene and propriety are commonly instrumentalised in both
directions. 3 Generally, in both low-income and middle class households,
women wash their own underwear and middle class women often noted that if
they stained their sheets during menstruation, they would wash these
themselves, even when they had domestic employees. Staining bed sheets, like
bleeding on one’s clothes raises similar issues regarding the permeability of the
house to domestic employees or visitors. Together, these cases reveal some
of the concerns people expressed with the leakage and effluence of menstrual
blood.
Maria de Jesus (cited above) evokes the state of corpo aberto (open body). In
Bahia, during illness, menstruation or following attack by a spirit or the jealous
intentions of a neighbour, the body is said to be “open.” Open body and the
attendant therapeutics of bodily sealing act upon the transformations of a body
understood to exist in continuity with the social, natural and metaphysical
environment. Techniques to close the body are concerned with restoring the
body’s capacity as a container, thus warding off harmful exogenous influences.
But closing the body does not make it bounded. In Bahia, although corpo aberto

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is a potentially dangerous bodily state – associated with possession by a spirit
or the devil – it is also recognised as necessary to the correct functioning of
the body, specifically the female body during menstruation or the post-partum
period, when periods of isolation were commonly observed.4
Given the importance of the idea of menstruation as a form of cleansing, the
expunged matter comes to be particularly charged. Within Afro-Brazilian
traditions, menstrual blood is considered polluting precisely because, as one
Candomblé authority explained, it is charged with “all that is bad” from a
woman’s body.5 Menstruation is often said to be a time when pregnancy can
occur, which is explained by the fact that during menstruation, the uterus is
open, hence allowing the semen to enter the woman’s body and fertilise her
blood (see Amaral 2003, Leal 1995). In a comparative study of African-
American medical systems (from North America and the Caribbean), Snow
(1998) reveals the recurrence of the idea that women are more vulnerable
when the uterus is open as well as of the general idea of a body permeable to
external forces.
Low-income women who, in the literature, are those who typically suffer from
nervoso, did not identify with this diagnosis in relation to menstruation. By
contrast, middle-class women frequently referred to nervoso in relation to the
sadness, impatience or anger experienced as part of what is widely referred to
in Bahia as pre-menstrual tension (PMT). However, middle-class women’s use
of the term nervoso differs substantially from that outlined in the literature on
nervoso in Latin America (e.g. Duarte 1986; Rebhun 1993; Scheper-Hughes
1992) which tends to describe nervoso within the frame of social suffering,
presenting nervoso as a condition that emerges out of difficult social conditions,
such as poverty and violence. The low-income women I interviewed did not
recognise the monthly alterations they experienced as PMT, which was often
qualified as frescura (affectation/sissiness) or, by one woman, as “attention
seeking.” This can be accounted for by the fact that, as Scheper-Hughes has
argued, suffering is a sign of força (strength). Scheper-Hughes show that for
low-income Brazilian women, “the rich and males” have força whilst the “poor
and females” have fraqueza (weakness). In this sense, when women spoke of
PMT as frescura, they directly challenged the categorisations Scheper-Hughes
relays, rejecting the equation between women and fraqueza.
In the public service family planning consultations I attended, women who
chose to use the IUD as a method of contraception are requested to come in
when they are menstruating as the cervix is dilated, facilitating insertion,
reducing pain, and ensuring – for the doctor – that the patient is not
pregnant.6 Given that menstrual blood is popularly considered as disgusting
women tend to be acutely embarrassed in this situation. Yet interestingly,
menstrual blood, and other bodily substances are treated with remarkable
normality in clinical contexts suggesting that – even where menstrual blood is
culturally marked as disgusting, as it is in Bahia – disgust is not a property of

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the blood itself, but of the context in which it is found. Drawing on her
extensive ethnographic work in Parisian hospitals, Pouchelle argues that
mastering disgust with regard to bodily humors is part of being a good
professional and that failure to do so is seen as a professional failure (Marie-
Christine Pouchelle, pers. com.). In my experience, when menstrual blood
formed part of the medical examination it was normal and not a cause a
disgust for doctors. Similarly, during vaginal or caesarean-section births, blood
flows freely, often onto the obstetricians’ ward-clothes or shoes, with no
apparent discomfort. However, once the specific protocols that produce
persons as patients and patients as bodies (and their fluids and body parts)
have been removed, and the full social person re-appears, menstrual blood was
commented upon in a way that signals a move from the blood legitimate within
normal clinical practice to the more ambivalent blood of the person. We can
read the ambivalence about menstrual blood in such contexts as revealing the
management of this transition from both the inside to the outside of the body
and from the passive patient-body to the (social) person. The point is that
menstrual blood is not in itself dirty or clean. The analytical focus should
therefore be on the relations that are produced by the dirt, or on the manner
in which, within particular relationships, menstrual blood is considered dirty. In
Bahia, it is the place such blood occupies, its provenance – whether it is in the
bin on an unconcealed sanitary napkin, in the toilet one sits on after someone
else, one’s own blood, a patient’s blood in the clinic, or a lover’s blood – that
carries the potential to disgust or not.

DETACHING BODY PARTS AND SUBSTANCES

Mary Douglas (2002, 1999, 1970) famously viewed bodily control as an
expression of social control and approached traditional society’s concerns
with pollution and modern concerns with hygiene as rituals whose primary
function were to maintain social order and the differentiations upon which it is
founded. Douglas defended the view that culturally defined attitudes to the
body reflect broader ideas about the control of social boundaries. She equated
the religious symbolism of a particular group, such as one which focuses on
boundaries (e.g. bodily boundaries) with the social structure of the group and
distinctions between group / non-group, etc. In this view, societies project
anxieties about the group’s integrity onto the body, and ritually attempt to
maintain group integrity through acting upon the body’s limits, and controlling
its effusions. Dirt, she famously proposed, troubles categories: it is “matter out
of place.” Essentially, Douglas’ approach, in evoking the breaching of
boundaries, puts the emphasis on bodily or social integrity. I would like to take
the problem the other way, as it were, and propose that we look at issues
concerning bodily boundaries as making, rather than unmaking, the body.
Despite the emphasis I give here to boundaries, I do not consider these as
either given nor fixed, but propose instead to call attention, ethnographically,

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to the process of their making. Douglas’ approach despite its attention to the
circulation of objects, concepts or substances across boundaries, retains a
view of the bounded thing as given. My critique of Douglas’ model arises from
my view that the body’s limits cannot be known a priori and that ethnographic
attention should be given to practices that bind bodies without assuming a
prior state of boundedness. A bodily surface may thus be located at different
points depending on the way in which the body itself is held together,
discursively. That is, the body’s boundary will vary depending on whether it is
dressed or naked, and whether the context of its nudity is, or not, made
socially appropriate through certain means (e.g. with an albeit very small bikini).
My argument is that much can be revealed about the negotiation of bodily
boundaries by tracing the way in which menstrual blood is managed in its
circulation across these. Menstrual blood raises questions concerning the
enclosures of the body, be they those of the presumed “natural” body – such
as the skin or surface orifices – or those of the “social” body – such as clothes.
I propose that we consider concerns expressed with leakage from the
perspective of the complex relationship between that which forms part of the
body, and that which is detached from it.
Whilst menstruation is often referred to as “the health of women,” menstrual
blood is widely characterised as sujo (dirty). This arises as a paradox for many
of the women I interviewed who commented on the fact that although they
appreciated the purifying and alleviative function of menstrual bleeding, they
were nevertheless inconvenienced by the blood, often referring to it as
repugnant, reeking, or unhygienic. However, menstruation also carries very
positive associations for many women, as an index of femininity or as a sign of
the good health of the body. As a cleansing process, menstruation brings about
physical and emotional relief, and women commonly speak of emerging
replenished from a period and alleviated by the release of blood. Yet this
notion of the purgeable body is increasingly being challenged by a version of
the body that is stable, self-contained and whose effluences are controlled. The
idea of menstruation as providing relief was often presented to me by medical
professionals as backwards and ignorant (see Sanabria 2009). The large-scale
promotion in Brazil of hormonal contraceptives which interfere with regular
menstruation has capitalised on these notions of hygiene. The menstrual
suppression debate – as it has come to be known – proposes that
menstruation is a waste of blood and that menstrual bleeding serves no such
“replenishing” function.
Kristeva (1982) – after Douglas – proposes that excluding “filth,” is the means
through which the “subject” is constituted, or against which it defines itself. In
shifting the focus from sociology to subjectivity, Kristeva introduces a radically
different notion of the boundary to that proposed by Douglas. In her work,
boundaries are ambiguous surfaces of negotiated possibilities. Kristeva’s theory
of the abject reveals that, even within the Judeo-Christian tradition, the inside
and the outside are not self-evident but are produced in a complex process

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which she associates with the emergence of a sense of self. In her model,
excretion and menstrual bleeding continually re-attest to the porous nature of
bodily boundaries. As I argue in what follows, the vagina (and the blood which
flows through it) is a particularly problematic threshold. Rather than
challenging the body’s integrity, I propose we view that which is detached from
the body, which falls away from it, and becomes abject as constructing the body.
In The Naked Man, Lévi-Strauss (1981:175) makes a brief reference to the
distinction recurrently made in Amerindian myth between that which is
separable from the body and that which is inseparable. Whilst eyes may be
introduced to stand for that which cannot be removed without injury,
excrement is destined to be removed at regular intervals. Teeth, in his analysis,
occupy an intermediary position, as aging may separate a person from their
teeth which had nevertheless felt to belong as much to the body as the eyes. I
want to use this apparently simple distinction (separable from the body :
inseparable from the body) to think about menstruation, menstrual blood and
menstrual suppression on the one hand and contemporary Bahian
gynaecological practice on the other. Whilst menstrual blood occupies a
position similar to excreta in this typology – in that it is removed at regular
intervals – menstruating, as a process, much like excretion, is, in Bahia,
intuitively felt to be part of the body’s normal functioning, and as such the
proposition to suppress the process tends to be accompanied (as is the case
globally) with a set of specific rationales. Unlike excretion, which is a function
that characterises the body throughout its existence, menstruation is a bodily
function that starts and stops at significant moments in a woman’s life, such as
menarche, pregnancy, stress, the influence of other women’s cycles or the
menopause. Contemporary discussions surrounding menstrual suppression
tend to centre on whether or not, given these more or less regular
intermissions in menstrual periods, menstruation is a fundamental and defining
aspect of what the female body is. The task at hand is to consider the specific
manner in which bodies are perceived in a context where it is commonly
stated that the uterus is “disposable” for women who have children, and in
which organs are routinely removed. For example, during a family planning
consultation I witnessed, a woman of twenty-three, mother to three children
came in requesting a referral for a tubal ligation (surgical sterilisation). The
doctor refused, justifying his decision in epidemiological terms by arguing that
it was counter-indicated in young women as it often led to abnormal uterine
swelling, requiring full hysterectomy within five years. “God, that would be a
blessing, why don’t you just remove the lot in one go!” the patient responded.
There is, therefore, nothing self-evident about the distinction Lévi-Strauss
proposes in the context I seek to describe.
Given the facility with which my informants envisage what in other contexts is
considered as intense surgical or biomedical intervention, I want to dwell
briefly on the question raised by the act of separating or removing something
from the body. I thus turn to Weiner’s (1995) The Lost Drum, in which he

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explores the relationship between the body and that which is ritually detached
from it in terms of Lacan’s notion of ‘dehiscence’, that is, the opening or
rupture of an object to release its contents. Concerns surrounding the proper
management of menstrual blood speak to the question of corporeal unity and
to the way in which, in Weiner’s (ibid.: 19) words, “the subject anticipates this
unity.” Weiner finds in Lacan’s objets petit a a Western counterpart to the
Melanesian themes of loss encompassment and caducity. In Weiner’s psycho-
analytically inflected reading of Melanesian myth, objects of exchange acquire
their specific value by refracting back to the subject “a more primordial stage
of undifferentiatedness” in which what is internal and external to the self are
not distinguishable (ibid.: xiv). The objects at the center of relations of
exchange are thereby intimately linked to what he calls “the orbit of the
body’s drives” (ibid.). The loss of the object/part is what makes it visible: “This
act of detachment creates a gap which allows relationality itself to become
visible” (ibid.). This is significant inasmuch as it is a proposition to view the
objets a—be they New Guinea pearl shells, flutes, or the bodily protrusions of
Lacan’s analysis— as simultaneously producing social relations (relations to
others) and relations to the self in a mirroring, recursive manner: “[Caducity]
is the discarded bit that serves as the marker of the body, that makes it visible.
We might say that the objets a are the elicited ground that allows the body to
stand forth as an ideal unity” (ibid.: 20).
How do such acts of detachment reflect back notions of completeness in
contexts where these notions are, supposedly, taken for granted? Pursuing the
avenue that Weiner opens, I now consider Kristeva’s (1982) concept of ‘the
abject’. Abjection seems a promising way of approaching the question of
menstruation in Bahia, as menstrual blood is often described by women as
nogente (disgusting) and sujo (dirty), and its everyday management, as we have
seen, reveals concerns with cleanliness and hygiene. Like Weiner—and
drawing on psychoanalytic theories—Kristeva is interested in dehiscence and
in the role that removing something from the body plays for the status of the
body. However, unlike Weiner, she does not examine the implications that
this has for the production of social relations. Her focus is on how excreted
bodily substances disturb identity. Kristeva argues that menstrual blood is
abject and that the abject generates disgust precisely because it is both ‘I’ and
‘not I’—it is what must fall away in order to produce the clean, proper body of
the subject. Kristeva and her commentators propose that female sexuality is
represented as an uncontainable flow, as seepage, as a vessel both containing
and contained, and that this inherent permeability of the female body affronts
the subject’s self-identity. It is read as a danger and as “a testimony of the
fraudulence or impossibility of the ‘clean’ and ‘proper’” (Grosz 1994: 194). The
question of what belongs to the body, and where its delimitations lie, is thus
deceptively clear-cut, even in contexts where the body’s integrity is seen as
relatively self-evident. Kristeva’s approach reveals the degree to which,
through disgust, horror, and rejection, subjects are involved in psychic

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processes of differentiation as a result of which the self emerges. In her
analysis of Western cultural production and myths, Kristeva (1982: 53)
describes the power of the “horror within,” which is con- stantly irrupting
upon the clean and proper self, exposing the way in which the body’s inside is
coded, within Western culture, as unclean.
Drawing on this idea and returning to the clinical context, I want to suggest
that we can break this down further as the constituents of the body’s depths
do not all carry the same potential for abjection. Pouchelle (2008), for example,
notes that in French hospitals, surgical interventions on organs that are
connected to the outside of the body (lungs, digestive organs, etc.) are
referred to by medical professionals as sales (dirty) whilst those carried out on
organs that are not connected to the outside of the body (e.g. the heart; the
brain) are propres (clean). This classification is understood to be based on
infectiology and serves as basis upon which the sequencing of surgical
interventions in operating theatres is organised, whereby clean surgeries come
before dirty ones. However, this classification is transsected by more cultural
notions of purity whereby heart or brain surgery are considered more noble.
Here the surgical incision is that which creates a passage from inside to
outside. What I want to argue therefore, is that it is not so much the inside
per se that is considered “unclean” but the various conduits that lead from the
inside, out.

SENSING THE VISCERAL BODY

In her classic study, Emily Martin (2001) reports that the language of failed
production and menstrual blood as waste material is prominent amongst
North American women. Her informants associate the menstrual flow with
the demise of an “egg” in the sequence of events at the heart of the biomedical
account of reproduction she so carefully deconstructs. She notes that “all
managed to get out some version of the failed production view”. In the
interviews that I carried out with women in Salvador, it is noteworthy that not
once was the notion of failed conception put forward to speak about
menstruation. The explanations Martin’s informants give turn on a causal
relationship between ovulation (“an egg”), its non-fertilisation and the
subsequent menstrual flow. In the Bahian accounts I collected, this causal
sequence was never alluded to. Narratives of menstruation did not connect
ovulation and menstruation explicitly. Óvulos (ovules) and the ovaries were
seldom evoked, whilst the útero (uterus) and hormônio (sex hormones) figured
very prominently in accounts about reproduction and menstruation.
The uterus seems more amenable to sense perception than the ovaries, whose
‘presence’—in Leder’s (1990) sense—is not as directly knowable.7 In this sense,
the uterus is a different kind of organ. This is a general, physiological specificity
of the uterus, deriving from its functions and the physical sensations that it

11
produces—a view that is significantly reinforced in Bahia. I would venture that
the uterus is more ‘present’ in Salvador than it is in the UK, for example. This
is the basis for my critique of Leder, whose model implies a pre-cultural basis
to visceral sense perceptions, suggesting that these are given in an unmediated
manner. The uterus is an organ with a particular presence. Because it is
traversed by muscular contractions during orgasm, menstruation, and labor, it
does not have the “foreignness to the inner body” that Leder (ibid.: 48)
describes. Given that the uterus is more amenable to sense perception than
Leder suggests, it is interesting that it is absent from his analysis of bodily
“depth disappearance” (ibid.: 53ff.).
In Bahia, as we have seen, this organ is given intentionality and autonomy in its
popular designation as the dona do corpo. In both popular and Afro-Brazilian
traditions, menstrual cramps are explained by reference to the dona do corpo,
said to be angry and circling the body causing pain. Herbal infusions are
administered to prevent this revolt and make the uterus return to “her”
normal place. Uterine prolapsis8 is explained as the dona do corpo coming out
of the body to look for the children that “she” bore into the world. Although
few middle class women today refer to the dona do corpo, the uterus remains
very present, although its evaluation has been replaced with a more medically
inflected language. The vivid presence of the uterus in Bahian discourse on
gender and the body opens up an interesting anthropological question: What
viscera are invested with “meaning,” and which are absent, or dys-appear?
How does sense perception (e.g. the fact that women feel their uterus more
than their liver) blend with the cultural valuation of particular organs? I
propose that we need a much more careful account of the different kinds of
phenomenological experiences afforded and culturally relayed by different
parts of the “visceral depths” than that proposed by Leder. In Bahia, the
phenomenological presence of the uterus is not disconnected to the fact that
this organ is open unto the outside of the body. In a sense, it is already
partially outside the body, and like the vagina – although one step removed – it
partakes in the zone of ambiguity between “inside” and “outside”.

12



FIGURES 1 AND 2 Women’s drawings of the reproductive organs,

showing the uterus opening to the outside of the body

Menstrual blood, which flows from the uterus and through the vagina is
interesting precisely for this reason. It comes from this purportedly absent
depth, and is turned ecstatically upon the world, to adopt Leder’s terminology.
But in his analysis, menstruation – like pregnancy, ageing and disease – are
moments of bodily dys-appearance. Leder recognises that there are problems
with categorising these types of embodied experiences within the model of
dys-appearance as they are “normal and necessary” and not “in themselves
dysfunctional or alienating” (1990:89). But, he concludes, “… aspects of this
heightened body awareness can be understood according to the model of dys-
appearance. While bodily states of rapid change need not be dysfunctional,
they are indeed problematic” (1990:90 emphasis added). For Leder, menstrual
blood is unaccountable because it does not obey the logic of the visceral-
surface distinction that he relies on; it constantly threatens to surface, refusing
to belong to either domain. Perhaps because of menstrual blood’s particular
material tangibility and qualities as a substance that comes from within but
mediates this inner world in a very directly experiential way, it is more readily
available to signification than, say, hormones or the ovaries. Nevertheless,
Leder’s model can be employed to ask about the importance of techniques
that seek to bring the “visceral circuitry” (ibid.: 51) to the surface, to make it
known. Leder suggests that “[o]nce made available in this [exteroceptive] form,
the subject can learn to control what before was involuntary. Self-knowledge
and self-command are thus achieved through technological mediation; what
was depth is artificially made to surface” (ibid.: 53).

13
 THE GYNAECOLOGICAL EXAMINATION
This relation between depth and surface is particularly evident in gynecological
examinations. Gynecological examinations are routine in Brazil and a key man-
ner in which women’s bodies are scrutinized by biomedicine. During
gynecological examinations, and given that the focus of attention is partially
concealed within the body, the emphasis on making visible and bringing into
view is striking. Luce Irigaray (in Olson and Worsham 2003: 126) defines the
morphology of the female body as “an open volume, one that can’t be
circumscribed.” For women of all social backgrounds, being ‘closed’ and being
‘open’ (symbolically played out in the gynecological examination) are both
valued at different moments, which accounts for the diversity of ways in which
these procedures are experienced. Ideals of virginity, such as closedness or
tightness, co-exist with sexual imperatives of openness, as epitomized in the
idiom of dar (to give, sexually). In the context of the gynecological examination,
the vagina emerges as a particularly ambiguous zone. Is the vagina inside or
outside the body? The following extract from one of my field reports attests
to the difficulties that this question raised for me:9

The doctor spoke as if she, the patient, were completely absent. Like all
patients I saw, she had been shaved neatly, and the set-up of the examination
table and sheet made her appear almost disembodied. As she lay waiting for
the examination to begin, blood emerged from her vagina. Despite the clinical
set-up, which rendered the patient’s body closer to the classic textbook
illustration, the red blood that seeped out attested to something else. It was
contentious in its effluence. Having commented casually on the afastamento
(lapsing) of the vaginal muscles in terms that implied something about the
patient’s sexuality, Dr. T. put on some fresh plastic gloves. Without a word of
warning, he introduced the metal speculum, proceeding in explanatory mode
as he shone the light into the canal made by the speculum. This immediately
filled up with menstrual blood, and again he commented on how much blood
there was. “Ta vendo [See]?” he asked. This was all about seeing. Seeing inside.
This rapid technical gesture, performed with the speculum, transformed the
vagina. The speculum produced a separation between the inside and the
outside of the body, disturbing the boundary that, notwithstanding the leaking
blood, had enclosed the inside of the vagina from view. While the neatly shorn
vagina that patients present for the gynecological examination is a boundary of
sorts (an object that conceals its inside), the menstruating vagina betrays the
exuding attribute that social practices of managing menstrual blood attempt to
conceal.

The vagina thus emerges as a kind of threshold or zone of ambiguity between

the inside and the outside of the body. This explains the way in which the
relative “openness” or “closedness” of the vagina is carefully negotiated
throughout gynaecological examinations where doctors encourage women to
relax, and open their body, enabling the examination. Yet simultaneously, this
situation provides a context for substantial disquisition on vaginal tightness,

14
revealing that laxness tends to be negatively viewed. On one occasion, a
woman in her mid-forties lay unconscious after an intervention on the
examination table of a public hospital. The marks on her body gave some
indication of her humble background. The doctor called my attention the
limpness of her transverse perineal muscles. Pointing to the way the
musculature had “sagged,” he inserts three gloved fingers into the patient’s
vagina, shaking them whilst stating: “Olha pra essa vagina tão frouxa, os músculos
estão todo afastados, essa mulher deve ter parido um bocado de filhos.” Look at
this totally loose vagina, the muscles are all lax, this woman must have birthed
a bunch of children. This “loose” vagina seemed to index for the doctor what
many middle class Bahians see as an “unbridled” reproductive capacity
amongst the “poor.”
The role of medical doctors in defining a normative relation to the body is
central in contemporary Brazil where doctors are often public figures.
Malcolm Montgomery, a gynaecologist from São Paulo who regularly appears
in the columns of Caras (the Brazilian equivalent of Hello magazine) and gave a
controversial interview to Brazil’s Playboy magazine, related to me in an
interview his tale of two sisters: the natureba (derogatory term for
“naturalist”) and the high-tech. The first, who was a hippy, went to live on a
farm and had four home-births and breastfed for years. The second was a
businesswoman, had two elective caesarean-sections followed by plastic
surgery and did not breastfeed. The latter is his patient, and at her fortieth
birthday he recently met her sister, younger by one year but “looking sixty at
least” with her greying hair, collapsed breasts and – he posited – prolapsed
uterus and rasgada (torn) vagina. Natural births, he told me, are violent and
aggressive; they distend the vagina and damage the perineum. They are “um
espetáculo de miséria estética (a spectacle of aesthetic misery)” he announced
proposing caesarean-sections as a means of humanising birth because they do
not mark women’s bodies in this way. Effectively, the vagina is demarcated as
the domain of sexuality rather than reproduction, and when the vagina is
“damaged” by childbirth, surgeries are carried out to tighten and repair it.
Post-natal reconstructive vaginal surgery is surprisingly common in Brazilian
public health services and linked to the idea that vaginal birth damages the
vagina, rendering it frouxa (lax).
One female gynaecologist who allowed me to observe her work in a public
maternity-unit in Salvador’s periphery presented the provision of these
surgeries through the public health service as a cheap way to “repair the
damaged perineum” of women who “have to give birth vaginally,” and suffer
from incontinence or vaginal prolapse as a result. That is to say, women who
give birth in the private health sector where the average rate of caesarean-
section is over 85% (rising to over 95% in some units) do not require this
procedure. Plástica vaginal includes a range of aesthetic and reconstructive
procedures which have gained media attention under rubriques such as plástica
da intimidade (intimacy plastic surgery) or vaginal “rejuvenation” surgery which

15
promise to boost sexual pleasure and self-esteem. The plásticas available to
low-income women through the SUS usually consist in a much simpler, low-
tech procedure (perinoplasty, or the sewing of the superficial transverse
perineal muscles) which nevertheless lends the kind of prestige associated with
having access to plastic surgery (on the “democratisation” of plastic surgery
amongst low-income Brazilians, see Edmonds 2007).
On one occasion, over lunch in the canteen of a public maternity-unit, a nurse
and a doctor expressed dismay at the lack of juiço (sense) a colleague had
shown in allowing a woman to give birth vaginally to a baby weighing four
kilograms. The nurse said the woman felt all rasgada (torn) to which the
doctor retorted:
Well at least she feels something! Her plástica vaginal (vaginal plastic surgery)
is going to have to be carried out by Odebrecht [large Latin American
engineering firm] with an architect and builders!
Doctors in the public service consultations regularly commented on vaginal
laxity or excessive tightness, raising this to my attention. On one occasion, a
patient who expressed pain during the insertion of the speculum was told, in
jest, that the surgeon who had realised her plástica had “done her too tight.”
In the course of fieldwork, several patients requested to be examined with a
paediatric speculum. For example, one patient went to substantial lengths – re-
scheduling her appointment and doubling the already extensive waiting time –
to ensure that she be examined with a paediatric speculum because, as she
publicly relayed in the corridor, “normal ones don’t fit.” The considered way
in which she was treated, despite upsetting normal clinical protocol, surprised
me. Despite the difficulties she created for the clinic’s staff, I sensed a degree
of approbation on their part that can be read as a mode of approving her
performance of sexual chastity. The distinction between being open
(penetrable) and closed (impenetrable) is heavily gendered in Bahia. Kulick
(1998), for example, shows how in male sexuality, it is the act of being
penetrated – not of engaging in sexual relations with other men – that indexes
homosexuality. However, many analyses of Brazilian sexuality (e.g. Parker
1991; Rebhun 1994) dwell on the fact that men are “closed” and women are
“open,” without considering that women’s bodies must perform both
functions, as these examples illustrate.
Whilst characterised by profound inequalities, Brazilian health statistics place
the country amongst the highest users of both female sterilization (estimated
at 36-40% of women of reproductive age, CEBRAP 2008) and caesarean-
section births that account for 40% of all births (McCallum 2005), and over
85% of births in the private health sector. Most surgical births are elective and
stem from a commonly held idea that caesarean-section births are less painful,
and prevent unnecessary damage to the vagina, which is in effect demarcated
as the domain of sexuality, rather than that of reproduction. McCallum’s
(2005) ethnography of birth in Salvador reveals that low-income women who

16
give birth vaginally in public hospitals are often neglected or badly treated. The
suffering associated with vaginal delivery is thus more than physical and comes
to include notions of stigma. Likewise, Denyer (2009) argues that low-income
women actively seek to be labeled ‘at risk’ during antenatal care in order to
ensure access to caesarean technology and avoid the discrimination associated
with a vaginal delivery. Beyond the stigma and search for best quality care,
McCallum reveals that:
The sexually adapted, attractive and active female body – the proper
condition of modern Brazilian women – is represented by untouched and
aesthetically pleasing genitalia. These genitalia, if also used for giving birth, lose
their power to signify modernity and progress. On the contrary, when
sexuality and reproduction become inter-linked through vaginal childbirth, the
meanings attached to the genitalia’s referent (the female body) are inverted.
Such a body is pre-modern, damaged. It is repulsive to others. (2005: 226-7)

In this sense, it can be argued that the plástica vaginal offered to low-income
women functions as a kind of proxy for the caesarean-section which are so
common among middle and upper class women.
This procedure, and the discursive practices surrounding the vagina and female
sexuality more generally, point to the ambiguity of this bodily threshold. The
vagina emerges as a zone that marks the boundary between the inside and the
outside of the body in uncertain ways. The practices observed in the context
of gynaecological examinations can be read as forms of working on this
boundary, of producing and managing it. But in the same way as the vagina is
already an ambivalent threshold between the inside and outside of the body, I
have suggested that the vivid presence in Bahia of the uterus can be
understood by the fact that this organ is itself open unto the outside of the
body. As women commonly stated, during menstruation, it is the uterus that
bleeds and whilst bleeding has a cleansing function, the blood itself is
particularly charged. I have argued that it is not the inside of the body that is in
itself viewed as “dirt” but rather the transition and the conduits that lead from
the inside, out.
Kristeva sees in the transition from the semiotics of biblical abomination that
characterises the Old Testament to the Gospels the rise of a new kind of
subject who has interiorised abjection. Defilement, in “Christic subjectivity” does
not originate from the outside but from within. The internalisation of
defilement – which in Leviticus is given material form – and its combination
with moral (symbolic) guilt produces “Sin” which, in the New Testament, is
already inscribed in the flesh. In this process the demoniacal/divine axis is
elaborated onto the distinction between inside and outside.
Before any relation to another is set up, and as if underlying it, it is the
building of that archaic space [the boundary between inside and outside], the
topological demarcation of the preconditions of a subjectivity, qua difference

17
 between a sub-ject and an ab-ject in the be-spoken being itself, that takes
over from earlier Levitical abominations. (Kristeva 1982:117)
This speaks to the emergence of a form of subjectivity that is intimately
connected to the production of a particular idea of the body’s interiority. This
visceral interiority, where ideas of the self emerge for the Christian subject is
– perhaps unsurprisingly, given the profoundly religious tenor of Brazilian
social life – carefully monitored, probed and scoped by the women I
encountered in Bahia. However, the exhortation to know oneself from the
inside, so to speak, is increasingly a medical, not a religious one.

18
ACKNOWLEDGEMENTS
Research towards this paper was made possible thanks to funding from the Economic
and Social Research Council and to the generous support of Cecilia McCallum, Estela
Aquino and Greice Menezes at the Instituto de Saúde Coletiva in Salvador. I am grateful
to Marilyn Strathern, Annemarie Mol, Simon Cohn and the participants of the Borders
Boundaries and Threshholds of the Body conference held in Cambridge in June 2009 for
comments on an earlier version of this paper.

NOTES
1. For a more detailed discussion on the topic of differences between private
and public health services, see Sanabria (2010).
2. On the division of space in Brazilian households and urban spaces, see
Holston (1989).
3. While middle-class employers often deplore what they see as their domestic
employees’ lack of hygiene, domestic workers also often commented to me on their
employers’ lack of cleanliness.
4. Several older informants felt that the loss of these practices of resguardo was
responsible for the numerous menstrual disorders that the younger generations are
experiencing today.
5. In this context, menstrual proscriptions can be seen as protecting women
since, during menstruation, the body ‘opens’ to release the charged blood, making a
woman particularly susceptible to negative forces, given her state of ‘open body’.
6. Concerns were commonly raised by several doctors whose work I observed
that—in the context of illegal abortion—women who know that they are pregnant
have IUDs inserted as a means of inducing an abortion.
7. Some women do feel ovulation; however, the existence of specific
technologies, such as fertility awareness charts and devices to chart the menstrual
cycle and identify when ovulation occurs, attests to the fact that this process is less
readily “brought to the surface” (Leder 1990: 105).
8. The sliding of the uterus from its normal position in the pelvic cavity into the
vaginal canal.
9. The relation that I established with doctors was modeled largely on their
relationship with medical students; thus, doctors would explain procedures to me in a
pedagogical manner. As a woman, I sometimes found the experience of being on the
‘other side’ of these medical examinations emotionally challenging. I explicitly asked
each patient if she minded my presence before entering the examining room. In these
contexts, casual conversation often served the function of normalizing a somewhat
incongruous situation. I generally stayed by the patient’s side, although some doctors
insisted that I sit by them during the examination, involving—for me—a complex
process of negotiation between different positionalities.
10. These procedures include labiaplasty (the reduction of the labia minora),
narrowing or reconstruction of the vaginal canal, ‘lipo-sculption’ of the pubic mound,
and whitening of the vulva.
11. On the ‘democratization’ of plastic surgery among low-income Brazilians, see
Edmonds (2007).

19
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